This mixed-methods study explored the benefits and limitations of a blended approach (mixing virtual and face-to-face consultations) to outpatient services for palliative care patients, to provide recommendations for future models of care. We found confirmatory findings from our quantitative and qualitative data for the appropriateness of a face-to-face consultation when there is a clinical concern or physical examination is required, and the use of telephone consultations for medication checks and review of stable symptoms. Physicians and patients both reported that communication via video was superior to telephone, but for certain situations remained inferior to an in-person consultation. The use of a blended approach to outpatient palliative care services was seen as positive by patients and physicians, allowing the value of in-person consultations to be balanced against the burden of attending appointments.

Consultation approach and communication

Our findings are in keeping with the wider literature exploring virtual consultations in palliative care. Prior studies have identified the importance of face-to-face consultations to establish and maintain a clinical relationship [26, 27], as well as to allow for a physical examination [26, 28]. In their qualitative study of telemedicine video visits for patients receiving palliative care, Tasneem and colleagues found that although participants did not feel that the overall relationship between themselves and their palliative care provider changed as a result of video consultations, they did feel a need to have occasional in-person visits to establish a stronger rapport with their physician and enable physical examinations [26]. Likewise, in their proof-of-concept study of elderly palliative care patients, Read and colleagues reported that participants felt in-person visits were better than web-based video consults in part due to concerns about their ability to accurately relay physical signs and information [28].

We found that patients and physicians reported telephone consultations to be practically convenient and suitable for routine reviews, in keeping with a 2016 systematic review of telephone consultations for cancer patients [29]. Our findings add the description of telephone consultations as a ‘triage’ service. This was seen positively by patients wanting immediate contact, but negatively by those for whom a second consultation was considered to be duplication. Previous studies have explored the acceptability of telephone consultations for delivering psychosocial support with mixed findings. Whilst some found that sensitive conversations can occur effectively [14], others found that professionals and patients may struggle to give and receive emotional support [29]. In our study only 5 of the 48 physicians surveyed stated that breaking bad news was appropriate over the telephone. By comparison, half of respondents felt that carer support could be provided, suggesting that there is scope for psychological support and rapport-building. Exploration of this topic with patients and caregivers highlighted the importance of the existing clinical relationship. Psychosocial support was considered more effective over the phone if a professional relationship already existed, suggesting that the depth of the relationship, rather than the content of the conversation, is more important, and may explain the variation in research findings to date.

Virtual consultations - gate-keeping and technology challenges

Patients are known to be more accepting of telemedicine than professionals [26, 30], particularly after face-to-face consultations [31]. Similarly, we found that whilst palliative care physicians felt face-to-face consultations were rarely inappropriate, patients emphasised the benefits of a blended service - namely that the value of in-person appointments should be balanced against the physical burden of attending appointments. Occasional clinical contact, even when well, was valued by patients, particularly those with a limited social network [32, 33], however we found less reliance on face-to-face consultations than shown previously, which may be a result of increased telemedicine use since the Covid-19 pandemic [34, 35]. Interestingly, physician respondents in this study frequently mentioned challenges they perceived patients to experience with video consultations, such as anxiety or practical inability, which contrasted with patients reported comfort. None of the 48 physicians suggested professional anxiety as a barrier, despite previous findings that staff can act as ‘gatekeepers’ to the use of technologies [36]. This shows that beyond the provision of, or access to, virtual technologies, there exists a barrier for patients in how the service is presented.

Separate to anxiety or practical inability, technological concerns are commonly raised as a barrier to the use of virtual technologies in healthcare - both by patients and healthcare professionals [12, 28]. Our study found similar concerns amongst healthcare professionals despite being conducted post the Covid-19 pandemic. Research has established that easily accessible and reliable technology, alongside adequate user training, are critical to the success of telehealth initiatives [37]. Whilst acceptability of virtual consultations increased during the pandemic, the importance of addressing the technological and training aspects of telemedicine when developing a virtual service remains. Even post-Covid-19, the two main barriers identified to the adoption of telemedicine were technical literacy and the need for technological development [6]. But self-reported scores of readiness to use video consultations improve with increased use [15], showing the impact of professional’s familiarity and confidence on successful incorporation.

Recommendations for clinical practice

We found evidence for patient benefit from integrating virtual and face-to-face consultations in outpatient palliative care services. Different modes should be used flexibly to support, rather than replace, each other, and a blended outpatient service should capitalise on the benefits that each approach delivers to provide an effective and efficient service. An overreliance on virtual consultations is potentially damaging and correlates with patients still valuing face-to-face consultations, whereas in-person only clinics can be burdensome in terms of travel and time for patients. In this study, the early introduction of video consultations is advocated to encourage future use when needed.

We recommend the following for outpatient palliative care services.

That face-to-face consultations:

1.

are used for an initial consultation; where there is a clinical concern; and, for situations that require a physical examination.

2.

should continue intermittently throughout the patient journey to support relationship building.

3.

may be best for psychosocial interventions and/or breaking bad news, dependent on patient preference and depth of professional relationship.

4.

are not always necessary for stable or predictable situations.

That telephone consultations are:

5.

appropriate for stable or predictable situations, medication reviews, and as a triage tool.

6.

feasible for delivering psychological support, dependent on patient preference and depth of professional relationship.

7.

inappropriate for complex consultations, particularly those with a physical component.

That video consultations are:

8.

introduced early in a patient journey to encourage familiarity.

9.

supported by telephone back-up.

10.

used to reduce the travel and time burden that patients experience when attending outpatient appointments.

11.

acceptable for psychosocial interventions and/or breaking bad news, dependent on patient preference and depth of professional relationship.

When developing a blended outpatient palliative care service adequate healthcare professional training alongside reliable, user-friendly technology is vital for successful implementation. We further recommend:

12.

integrating different modes of consultation early in a patient journey without over-reliance on one mode.

13.

that patient preference be a key factor when choosing consultation mode, acknowledging that clinician guidance for the most appropriate modality is also valued by patients.

Strengths and limitations

A strength of this study is its use of mixed methods to explore a complex intervention. By combining both quantitative data from palliative care physicians with qualitative data from patients and caregivers we were able to explore the benefits and limitations of different consultation formats to a greater extent. We also used our findings to develop practical recommendations for clinical practice.

Limitations of our study include the small sample sizes for both components. For the online survey (component 1) information about the study and a link to access the survey was sent to all members of the Association of Palliative Medicine via email as part of their quarterly bulletin. The email distribution list contains 1,300 palliative care professionals but we do not have information about how many of these people read the emails and/or how many of those on the mailing list would meet the study’s eligibility criteria. We were therefore not able to determine the actual response rate, but anticipate that this was low, meaning our findings may be less representative of a wider population.

Our qualitative component was also limited to patients and caregivers recruited via one hospice site and to those who could use MS Teams. This limited the generalisability of our findings by restricting our sample to those capable of handling the necessary IT. Future research exploring the views of those who do not have access to, or experience of, virtual technologies would be valuable.

Lastly, our patients were recruited from hospice outpatient clinics, whereas most of the palliative care physicians that responded to our online survey worked in a hospital setting which limited the strength when triangulating our findings.